All surgical procedures must be carefully planned. The patient should be adequately prepared medically, psychologically, and practically for all aspects of the intervention. This chapter covers the preparation of the patient and the general considerations that are common to all periodontal surgical techniques. Complications that may occur during or after surgery are also discussed.
Surgical periodontal procedures are usually performed in the dental office. Hospital periodontal surgery is discussed later in this chapter, and this is followed by a review of common surgical instruments.
Almost every patient undergoes the so-called initial or preparatory phase of therapy, which basically consists of thorough scaling and root planing and the removing of all irritants responsible for the periodontal inflammation. These procedures do the following: (1) eliminate some lesions entirely; (2) render the tissues more firm and consistent, thereby allowing for a more accurate and delicate surgery; and (3) acquaint the patient with the office, the operator, and his or her assistants, thereby reducing the patient’s apprehension and fear.
The reevaluation phase consists of reprobing and reexamining all of the pertinent findings that previously indicated the need for the surgical procedure. The persistence of these findings confirms the indication for surgery. The number of surgical procedures, the expected outcome, and the postoperative care necessary are all determined before therapy. These are discussed with the patient, and a final decision is made that incorporates any necessary adjustments to the original plan.
For patients who are not medically compromised, the value of administering antibiotics routinely for periodontal surgery has not been clearly demonstrated.29 However, some studies have reported reduced postoperative complications, including reduced pain and swelling, when antibiotics are given before periodontal surgery and continued for 4 to 7 days after surgery.4,12,21,32
The prophylactic use of antibiotics in patients who are otherwise healthy has been advocated for bone-grafting procedures and purported to enhance the chances of new attachment. Although the rationale for such use appears logical, no research evidence is available to support it. In any case, the risks inherent to the administration of antibiotics should be evaluated together with the potential benefits. Other presurgical medications include the administration of a nonsteroidal anti-inflammatory drug such as ibuprofen (e.g., Motrin) 1 hour before the procedure as well as the use of a mouthrinse with 0.12% chlorhexidine gluconate (Peridex, PerioGard).38
The deleterious effect of smoking on the healing of periodontal wounds has been amply documented20,33,43 (see Chapter 10). Patients should be clearly informed of this fact and asked to quit smoking completely or to at least stop smoking for a minimum of 3 to 4 weeks after the procedure. For patients who are unwilling to follow this advice, an alternate treatment plan that does not include more sophisticated techniques (e.g., regenerative, mucogingival, aesthetic) should be considered.
The patient should be informed at the initial visit about the diagnosis, prognosis, and different possible treatments his or her condition, with the expected results and all pros and cons of each approach discussed as well. At the time of surgery, the patient should again be informed, verbally and in writing, of the procedure to be performed, and he or she should indicate his or her agreement to undergo the procedure by signing the consent form.
The most common emergency is syncope, which is a transient loss of consciousness caused by a reduction in cerebral blood flow. The most common causes of syncope are fear and anxiety. Syncope is usually preceded by a feeling of weakness, and then the patient develops pallor, sweating, coldness of the extremities, dizziness, and a slowing of the pulse. The patient should be placed in a supine position with the legs elevated; tight clothes should be loosened, and a wide-open airway should be ensured. The administration of oxygen is also useful. Unconsciousness may persists for a few minutes. A history of previous syncopal attacks during dental appointments should be explored before treatment is begun; if these are reported, extra efforts to relieve the patient’s fear and anxiety should be made. The reader is referred to other texts for a complete analysis of this important topic.3
The danger of transmitting infections to the dental team or other patients has become apparent in recent years, particularly with the threat of acquired immunodeficiency syndrome and hepatitis B virus infection. Universal precautions (e.g., protective attire) and barrier techniques are strongly recommended and often required by law. These include the use of disposable sterile gloves, surgical masks, and protective eyewear. All surfaces that may possibly be contaminated with blood or saliva and that cannot be sterilized (e.g., light handles, unit syringes) must be covered with aluminum foil or plastic wrap. Aerosol-producing devices (e.g., Cavitron) should not be used on patients with suspected infections, and their use should be kept to a minimum in all other patients. Special care should be taken when using and disposing of sharp items such as needles and scalpel blades.
Periodontal surgery should be painless for the patient. He or she should be assured of this at the outset and throughout the procedure. The most reliable means of providing painless surgery is the effective administration of local anesthesia. The area to be treated should be thoroughly anesthetized by means of regional block and local infiltration. Injections directly into the interdental papillae may also be helpful.
Apprehensive and neurotic patients require special management with anti-anxiety or sedative–hypnotic agents. Modalities for the administration of these agents include inhalation, oral, intramuscular, and intravenous routes. The specific agents and the modality of administration are based on the desired level of sedation, the anticipated length of the procedure, and the overall condition of the patient. Specifically, the patient’s medical history and his or her physical and emotional statuses should be considered when selecting agents and techniques.
Perhaps the simplest, least invasive method to alleviate anxiety in the dental office is nitrous oxide and oxygen inhalation sedation. For many individuals, this is quite effective. Advantages include a quick onset of action, the ability to adjust the level of sedation throughout the procedure, a rapid recovery, and little or no concern for postoperative impairment of sensory or motor function. One disadvantage is that a small percentage of patients will not achieve the desired effect. This is especially true for the mentally impaired individual, because nitrous oxide and oxygen sedation requires some level of patient cooperation. Overall, inhalation sedation with nitrous oxide and oxygen is a safe, effective, and reliable means of reducing mild anxiety.
For individuals with mild to moderate anxiety, oral administration of a benzodiazepine can be effective to decrease anxiety and to produce a level of relaxation. The oral administration of a sedative agent can be more effective than inhalation anesthesia, because the level of sedation achieved may be more profound. Disadvantages of oral sedative administration include incomplete recovery, an inability to control the level of sedation, and a prolonged period of impaired sensory and motor skills. A variety of benzodiazepine agents are available for oral administration (see Chapter 36).
The intravenous administration of a benzodiazepine, either alone or in combination with other agents, can be used to achieve a greater level of sedation in individuals with moderate to severe levels of anxiety. Furthermore, the onset of action of intravenous sedation is almost immediate, and the level of sedation can be titrated on an individual basis to the desired effect. The recovery period depends on the half-life of the agent used and the amount given. The operator should receive formal training in the techniques of sedation; this often is required by law. A thorough understanding of the indications, contraindications, and risks of these agents is required.3 The reader is referred to Chapter 36 and other texts for a more detailed discussion of conscious sedation modalities, agents, and techniques.26
1. Operate gently and carefully. In addition to being most considerate to the patient, this is also the most effective way to operate. Tissue manipulation should be precise, deliberate, and gentle. Thoroughness is essential, but roughness must be avoided, because it produces excessive tissue injury, causes postoperative discomfort, and delays healing.
2. Observe the patient at all times. It is essential to pay careful attention to the patient’s reactions. Facial expressions, pallor, and perspiration are distinct signs that may indicate that the patient is experiencing pain, anxiety, or fear. The physician’s responsiveness to these signs can be the difference between success and failure.
3. Be certain that the instruments are sharp. Instruments must be sharp to be effective; successful treatment is not possible without sharp instruments. Dull instruments inflict unnecessary trauma as a result of poor cutting and excessive force applied to compensate for their ineffectiveness. A sterile sharpening stone should be available on the operating table at all times.
Although scaling and root planing have been performed previously as part of Phase I therapy, all exposed root surfaces should be carefully explored and planed as needed as part of the surgical procedure. In particular, areas of difficult access (e.g., furcations, deep pockets) often have rough areas or even calculus that was undetected during the preparatory sessions. The assistant who is retracting the tissues and using the aspirator should also check for the presence of calculus and the smoothness of each surface from a different angle.
Hemostasis is an important aspect of periodontal surgery, because good intraoperative control of bleeding permits an accurate visualization of the extent of disease, the pattern of bone destruction, and the anatomy and condition of the root surfaces. It provides the operator with a clear view of the surgical site, which is essential for wound debridement and scaling and root planing. In addition, good hemostasis also prevents the excessive loss of blood into the mouth, oropharynx, and stomach.
Periodontal surgery can produce profuse bleeding, especially during the initial incisions and flap reflection. After flap reflection and the removal of granulation tissue, bleeding disappears or is considerably reduced. Typically, the control of intraoperative bleeding can be managed with aspiration. Continuous suctioning of the surgical site with an aspirator is indispensable when performing periodontal surgery. The application of pressure to the surgical wound with moist gauze can be a helpful adjunct to control site-specific bleeding. Intraoperative bleeding that is not controlled with these simple methods may indicate a more serious problem and require additional control measures.
Excessive hemorrhaging after initial incisions and flap reflection may be caused by the laceration of venules, arterioles, or larger vessels. Fortunately, the laceration of medium or large vessels is rare, because incisions near highly vascular anatomic areas (e.g., the posterior mandible [the lingual and inferior alveolar arteries], the posterior mid-palatal regions [the greater palatine arteries]) are avoided by incision and flap procedures. Proper design of the flaps, which takes these areas into consideration, avoids accidents (see Chapter 53). However, even when all anatomic precautions are taken, it is possible to cause bleeding from medium or large vessels, because anatomic variations do occur and may result in inadvertent laceration. If a medium or large vessel is lacerated, a suture around the bleeding end may be necessary to control hemorrhage. Pressure should be applied through the tissue to determine the location that will stop blood flow in the severed vessel. A suture can then be passed through the tissue and tied to restrict blood flow. Excessive bleeding from a surgical wound may also result from incisions across a capillary plexus. Minor areas of persistent bleeding from capillaries can be stopped by applying cold pressure to the site with moist gauze (soaked in sterile ice water) for several minutes.
The use of a local anesthetic with a vasoconstrictor may also be useful for controlling minor bleeding from the periodontal flap. Both of these methods act through vasoconstriction, thereby reducing the flow of blood through incised small vessels and capillaries. This action is relatively short lived, and it should not be relied on for long-term hemostasis. It is important to avoid the use of vasoconstrictors to control bleeding before sending a patient home. If a more serious bleeding problem exists or if a firm blood clot is not established, bleeding is likely to recur when the vasoconstrictor has metabolized and the patient is no longer in the office.
For a slow constant blood flow and for oozing, hemostasis may be achieved with hemostatic agents. Absorbable gelatin sponge (Gelfoam), oxidized cellulose (Oxycel), oxidized regenerated cellulose (Surgicel Absorbable Hemostat), and microfibrillar collagen hemostat (CollaCote, CollaTape, CollaPlug) are useful hemostatic agents for the control of bleeding in capillaries, small blood vessels, and deep wounds (Table 55-1).
|Generic (Brand)||Directions||Adverse Effects||Precautions|
|Absorbable gelatin sponge (Gelfoam)||May be cut into various sizes and applied to bleeding surfaces||May form nidus for infection or abscess||Should not be overpacked into extraction site or wound—may interfere with healing|
|Oxidized cellulose (Oxycel)||Most effective when applied to wound dry as opposed to moistened||May cause foreign-body reaction||Extremely friable and difficult to place; should not be used adjacent to bone—impairs bone regeneration; should not be used as a surface dressing—inhibits epithelialization|
|Oxidized regenerated cellulose (Surgicel Absorbable Hemostat)||May be cut to various shapes and positioned over bleeding sites; thick or excessive amounts should not be used||Encapsulation, cyst formation, and foreign-body reaction possible||Should not be placed in deep wounds—may physically interfere with wound healing and bone formation|
|Microfibrillar collagen hemostat (CollaCote, CollaTape, CollaPlug)||May be cut to shape and applied to bleeding surface||May potentiate abscess formation, hematoma, and wound dehiscence; possible allergic reaction or foreign-body reaction||May interfere with wound healing; placement in extraction sockets has been associated with increased pain|
|Thrombin (Thrombostat)||May be applied topically to bleeding surface||Allergic reaction can occur in patients with known sensitivity to bovine materials||Must not be injected into tissues or vasculature—can cause severe (and possibly fatal) clotting|
Absorbable gelatin sponge is a porous matrix prepared from pork skin that helps to stabilize a normal blood clot. The sponge can be cut to the desired dimensions and either sutured in place or positioned within the wound (e.g., an extraction socket). It is absorbed in 4 to 6 weeks.
Oxidized regenerated cellulose is prepared from cellulose via a reaction with alkali to form a chemically pure and more uniform structure than oxidized cellulose. The material is prepared in a cloth or thin gauze form that can be cut to the desired size and sutured or layered on the bleeding surface. It can be used as a surface dressing because it does not impair epithelialization, and it is bactericidal against many gram-negative and gram-positive microorganisms that are both aerobic and anaerobic. Caution should be used when wounds are infected or have an increased potential to becoming infected (e.g., immunocompromised patients), because the absorbable hemostatic agents can serve as a nidus for infection.
Thrombin is a drug that is capable of hastening the process of blood clotting. It is intended for topical use only, and it is applied as a liquid or powder. Thrombin should never be injected into tissues, because it can cause serious or even fatal intravascular coagulation. In addition, because thrombin is a bovine-derived material, caution should be used for any patient with a known allergic reaction to bovine products.
Finally, it is imperative to recognize that excessive bleeding may be caused by systemic disorders, including (but not limited to) platelet deficiencies, coagulation defects, medications, and hypertension. As a precaution, all surgical patients should be asked about any current medications that may contribute to bleeding, any family history of bleeding disorders, and any hypertension. All patients, regardless of health history, should have their blood pressure evaluated before surgery, and anyone who is diagnosed with hypertension must be advised to see a physician before surgery. Patients with known or suspected bleeding deficiencies or disorders must be carefully evaluated before any surgical procedure. A consultation with the patient’s physician is recommended, and laboratory tests should be performed to assess the risk of bleeding. It may be necessary to refer the patient to a hematologist for a comprehensive workup.
In most cases, after the surgical periodontal procedures are completed, the area is covered with a surgical pack. In general, dressings have no curative properties; they assist healing by protecting the tissue rather than providing “healing factors.” The pack minimizes the likelihood of postoperative infection and hemorrhage, facilitates healing by preventing surface trauma during mastication, and protects the patient from pain induced by contact of the wound with food or with the tongue during mastication. (For a complete literature review on this subject, see the article by Sachs and colleagues.37)
Packs that are based on the reaction of zinc oxide and eugenol include the Wondr Pak, which was developed by Ward46 in 1923, and several other packs that use modified forms of Ward’s original formula. The addition of accelerators such as zinc acetate gives the dressing a better working time.
Zinc oxide–eugenol dressings are supplied as a liquid and a powder that are mixed before use. Eugenol in this type of pack may induce an allergic reaction that produces reddening of the area and burning pain in some patients.
The reaction between a metallic oxide and fatty acids is the basis for the Coe-Pak, which is the most widely used dressing in the United States. This is supplied in two tubes, the contents of which are mixed immediately before use until a uniform color is obtained. One tube contains zinc oxide, an oil (for plasticity), a gum (for cohesiveness), and Lorothidol (a fungicide); the other tube contains liquid coconut fatty acids that have been thickened with colophony resin (or rosin) and chlorothymol (a bacteriostatic agent).37,40 This dressing does not contain asbestos or eugenol, thereby avoiding the problems associated with these substances.
Other noneugenol packs include cyanoacrylates6,19,24 and tissue conditioners (methacrylate gels).2 However, these are not in common use.
Periodontal dressings are usually kept in place mechanically by interlocking in interdental spaces and joining the lingual and facial portions of the pack. In isolated teeth or when several teeth in an arch are missing, retention of the pack may be difficult. Numerous reinforcements and splints and stents for this purpose have been described.17,18,47 The placement of dental floss tied loosely around the teeth enhances retention of the pack.
Improved healing and patient comfort with less odor and taste6 have been obtained by incorporating antibiotics into the pack. Bacitracin,5 oxytetracycline (Terramycin),13 neomycin, and nitrofurazone have been tried, but all of these may produce hypersensitivity reactions. The emergence of resistant organisms and opportunistic infections has been reported.35 The incorporation of tetracycline powder into the Coe-Pak is generally recommended, particularly when long and traumatic surgeries are performed.
The Coe-Pak is prepared by mixing equal lengths of paste from tubes that contain the accelerator and the base until the resulting paste is a uniform color (Figure 55-1, A to C). A capsule of tetracycline powder can be added at this time. The pack is then placed in a cup of water at room temperature (Figure 55-1, D). After 2 to 3 minutes, the paste loses its tackiness, and it can be handled and molded; it remains workable for 15 to 20 minutes. The working time can be shortened by adding a small amount of zinc oxide to the accelerator (pink paste) before spatulating.
The pack is then rolled into two strips that are approximately the length of the treated area. The end of one strip is bent into a hook shape and fitted around the distal surface of the last tooth to approach that tooth from the distal surface (Figure 55-2, A). The remainder of the strip is brought forward along the facial surface to the midline and gently pressed into place along the gingival margin and interproximally. The second strip is applied from the lingual surface. It is joined to the pack at the distal surface of the last tooth and then brought forward along the gingival margin to the midline (Figure 55-2, B). The strips are joined interproximally by applying gentle pressure on the facial and lingual surfaces of the pack (Figure 55-2, C). For isolated teeth separated by edentulous spaces, the pack should be made continuous from tooth to tooth to cover the edentulous areas (Figure 55-3).